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August 14, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
This Week’s Featured Articles
Aikens RC, Chen JH, Baiocchi M, et al. Med Decis Making. 2024;44(5):481-496.
Large electronic health record- or population-based datasets form the basis for many diagnostic error studies. This article raises the issue of data-driven feedback loop failures which occur when disease incidence, presentation, and risk factors are misunderstood in research and, therefore, future medical practice. For example, men presenting with "classic" symptoms of heart attack are more frequently targeted for evaluation than women with "atypical" symptoms, thereby resulting in underdiagnoses of heart attack in women and underrepresentation in the evidence base.
Badr S, Nahle T, Rahman S, et al. J Gen Intern Med. 2024;Epub Jul 19.
Patients and families can look at various rating systems to compare hospitals, nursing homes, and other healthcare providers. This study compared ratings of four national hospital rating organizations: Hospital Compare, Healthgrades, The Leapfrog Group, and US News and World Report. The results showed discordance between hospital ratings on several important overall and condition-specific measures, potentially causing confusion for patients seeking care.
Nguyen PTL, Phan TAT, Vo VBN, et al. Int J Clin Pharm. 2024;Epub May 11.
The fast-paced and complex environment of the emergency department (ED) can threaten patient safety. In this meta-analysis, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death.
Estrada Alamo CE, Diatta F, Monsell SE, et al. Anesth Analg. 2024;138(5):938-950.
As interest in artificial intelligence (AI) in healthcare is increasing, clinician attitudes towards its integration are important to understand. In this study, about half of surveyed physician anesthesiologists had a positive attitude towards using AI in clinical practice and a similar proportion were curious about its use. Concerns included lack of transparency in AI algorithms, potential decreased earnings, and malpractice claims.
Oster CA, Woods E, Mumma J, et al. Jt Comm J Qual Patient Saf. 2024;Epub Jun 1.
Investigating safety events can help healthcare organizations improve systems and processes to prevent future incidents. This article describes the development of an electronic apparent cause analysis (eACA) tool, which combines features from high reliability, human factors engineering, and just culture, to investigate and learn from near-miss safety events or events resulting in minimal harm.
Aikens RC, Chen JH, Baiocchi M, et al. Med Decis Making. 2024;44(5):481-496.
Large electronic health record- or population-based datasets form the basis for many diagnostic error studies. This article raises the issue of data-driven feedback loop failures which occur when disease incidence, presentation, and risk factors are misunderstood in research and, therefore, future medical practice. For example, men presenting with "classic" symptoms of heart attack are more frequently targeted for evaluation than women with "atypical" symptoms, thereby resulting in underdiagnoses of heart attack in women and underrepresentation in the evidence base.
Didion L, Whitfield C, Bishop P, et al. J Patient Saf. 2024;20(5):375-380.
Health systems are increasingly aiming to become high reliability organizations. This safety net hospital established systems for high reliability through leadership, safety culture, and robust process improvement with targeted areas for improvement in patient outcomes, public reputation, and lower cost of care. Patient outcomes (e.g., reduction in hospital-acquired infections) improved, which subsequently improved Hospital Compare star ratings. Efforts to achieve lower costs of care continue with improved efficiency of care and educating all clinicians on their contributions to hospital finances.
Badr S, Nahle T, Rahman S, et al. J Gen Intern Med. 2024;Epub Jul 19.
Patients and families can look at various rating systems to compare hospitals, nursing homes, and other healthcare providers. This study compared ratings of four national hospital rating organizations: Hospital Compare, Healthgrades, The Leapfrog Group, and US News and World Report. The results showed discordance between hospital ratings on several important overall and condition-specific measures, potentially causing confusion for patients seeking care.
Porter-Stransky KA, Horneffer-Ginter KJ, Bauler LD, et al. BMC Med Educ. 2024;24(1):800.
Psychological safety is when team members feel comfortable speaking up without fear of negative consequences. This study evaluated a multi-year medical school-wide initiative to improve psychological safety through education, departmental champions, and leadership training. The researchers identified significant improvements in employees’ perceptions of psychological safety at the departmental level but not institution-wide.
Adkins TJ, Zhang H, Lee TG. Nat Commun. 2024;15(1):6422.
In order to improve patient safety, it is important to understand behaviors and decision making following an error. This article explores the concept of post-error slowing. Through four experiments, researchers determined post-error slowing is not simply due to increased caution, but due to impaired cognitive processing, and leads to even more mistakes.
Jennings AA, Doherty AS, Clyne B, et al. Age Ageing. 2024;53(6):afae116.
An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new symptom resulting in the initiation of a new medication. Interviews were conducted with patients, caregivers, physicians, pharmacists, and other experts for their perspectives on prescribing cascades in older adults. Adverse drug events, and therefore prescribing cascades, were accepted as unavoidable for older adults taking multiple medications. Clinicians felt challenged when balancing risks and benefits of further prescribing. None of the stakeholder groups felt like they had adequate information for a safe medication reconciliation which presents a missed opportunity to identify and stop prescribing cascades.
No results.
Howell MD. BMJ Qual Saf. 2024;Epub Jul 24.
Artificial intelligence (AI) is transforming the way researchers and clinicians seek to improve patient safety. This article provides a primer on AI terminology (e.g., generative AI, large language models), opportunities for it to improve patient safety, and challenges such as bias and hallucinations.
Malgrat-Caballero S, Kannukene A, Orrego C. J Healthc Qual Res. 2024; Epub Jul 15.
Residents of long-term care facilities are particularly vulnerable to patient safety risks. This systematic review including 66 studies evaluated tools used to identify adverse events in intermediate and long-term care centers (ILCCs). The authors found that most tools are designed to identify specific adverse events or safety risks (such as medication errors, falls, or infections). Common adverse events impacting this population include adverse drug events, delirium, malnutrition, pressure ulcers, and infections.
Nguyen PTL, Phan TAT, Vo VBN, et al. Int J Clin Pharm. 2024;Epub May 11.
The fast-paced and complex environment of the emergency department (ED) can threaten patient safety. In this meta-analysis, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death.
Flynn C, Watson C, Patton D, et al. J Pediatr Nurs. 2024;Epub Jul 16.
Burnout is often referred to as a psychological syndrome, characterized by feelings of energy depletion, dissociation from one's work or cynicism regarding one's job, and a reduction in professional efficacy. This review highlights the association of pediatric nurses' burnout and perceptions of patient safety. The studies showed a negative association between burnout and/or its individual components and safety attitude scoring and job satisfaction. Only four studies were identified, highlighting the need for more research into the emotional well-being of pediatric nurses.
United States Meeting/Conference
University of Minnesota, UCSF Coordinating Center for Diagnostic Excellence. University of Minnesota Masonic Children's Hospital. Minneapolis, MN. October 13-14, 2024.
Achieving diagnostic excellence is a key objective for those in the patient safety community. The Diagnostic Excellence 2024 (DEX24) meeting, jointly sponsored by the University of Minnesota and the UCSF Coordinating Center for Diagnostic Excellence, will highlight avenues to advance diagnostic excellence, including how artificial intelligence (AI) can be used to further diagnostic excellence in research, education, and practice.
Meeting/Conference Proceedings
Institute for Healthcare Improvement. August 19, 2024.
Artificial intelligence (AI) is rapidly expanding across a wide range of clinical and administrative health care functions. This webinar examined general AI implementation recommendations and examine its potential impact on the safety of clinical decision support, consumer-facing automated support tools, and records support.
Audiovisual
First L. NBC5. August 1, 2024.
Medication mistakes involving children are common. This news segment provides suggestions for parents to help improve the safety of medication use with children at home. Tactics emphasized include caution regarding use of household spoons to dose liquid medications.
Special or Theme Issue
Watts PI. Nurs Clin North Am. 2024;59(3):345-510.
Simulation is an established method to examine nursing process resilience and develop non-technical skills to improve safety. Articles in this special issue cover topics such as team communication improvement, debriefing practices, and simulation training experience design.
Press Release/Announcement
Fed Register. July 31, 2024;7575:61427-61428.
Surveys are acknowledged tools that enhance healthcare organizational knowledge of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Medical Office Survey on Patient Safety Culture Database information collection process. The deadline for submitting comments on this notification is September 30, 2024.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD |
A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.
WebM&M Cases
Commentary by Brittany Newton, PharmD and Roslyn Seitz, MPH, MSN |
An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.
WebM&M Cases
Commentary by Robert M. Szabo, MD, MPH, FAOA |
A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon
This Month’s Perspectives
Perspectives on Safety
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
Dr. Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the Assistant Vice President for Patient Safety at Inova Health System. We spoke to them about Safety-II principles and their application at Inova.
Perspective
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
This piece provides an overview of Safety-II principles and discusses ways healthcare systems are integrating Safety-II principles into safety programs and care delivery.
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